NAFLD: A Practical Approach to Diagnosis and Staging
NAFLD: A Practical Approach to Diagnosis and Staging
NAFLD is very common and the majority of patients have mild disease, but patients with advanced NASH need to be identified to offer treatment and surveillance for liver-related complications. With the current lack of a simple, widely available biomarker for NASH, a pragmatic diagnostic and staging approach is needed. One such approach for the investigation and assessment of disease severity in patients with NAFLD is shown in figure 1.
(Enlarge Image)
Figure 1.
Example of algorithm for clinical assessment of patients at risk of non-alcoholic fatty liver disease. CK-18 levels are not routinely available in many centres, so patients at intermediate and high risk have to be managed according to the high-risk arm of the algorithm (red arrows). 'Screen'- blood tests to rule out common causes of liver disease; USS, ultrasound; MS, metabolic syndrome; IR, insulin resistance; HCC, hepatocellular carcinoma.
In brief, the first stage involves the identification of patients with NAFLD either with metabolic risk factor profiling, LFTs or imaging. If steatosis is confirmed and other causes of liver disease are excluded, a clinical diagnosis of NAFLD can be made. The second stage involves risk stratification to determine a patient's stage of disease. This should be initially undertaken non-invasively with a locally available test (eg, FIB-4 score, NAFLD fibrosis score, TE, ARFI, CK-18). Patients who are identified as 'low' risk of NASH or advanced fibrosis can be managed in primary care with modification of their metabolic risk factors. Patients who are 'indeterminate' or 'high' risk should undergo further assessment (often requiring a liver biopsy) to determine the stage of disease. Risk stratification means patients can then be managed appropriately as will be discussed in 'Non-alcoholic fatty liver disease: a practical approach to management' by Dyson et al65a.
Machado et al have recently proposed a similar algorithm for patients with NAFLD to guide when liver biopsy is needed. They used the NAFLD Fibrosis Score and TE to evaluate fibrosis and CK-18 fragments to evaluate NASH. The management pathway for patients would be very similar as with the algorithm we propose, but CK-18, and even TE, are not available in many centres, which is reflected in our algorithm.
A Pragmatic Approach to Diagnosis and Staging of NAFLD in Clinical Practice
NAFLD is very common and the majority of patients have mild disease, but patients with advanced NASH need to be identified to offer treatment and surveillance for liver-related complications. With the current lack of a simple, widely available biomarker for NASH, a pragmatic diagnostic and staging approach is needed. One such approach for the investigation and assessment of disease severity in patients with NAFLD is shown in figure 1.
(Enlarge Image)
Figure 1.
Example of algorithm for clinical assessment of patients at risk of non-alcoholic fatty liver disease. CK-18 levels are not routinely available in many centres, so patients at intermediate and high risk have to be managed according to the high-risk arm of the algorithm (red arrows). 'Screen'- blood tests to rule out common causes of liver disease; USS, ultrasound; MS, metabolic syndrome; IR, insulin resistance; HCC, hepatocellular carcinoma.
In brief, the first stage involves the identification of patients with NAFLD either with metabolic risk factor profiling, LFTs or imaging. If steatosis is confirmed and other causes of liver disease are excluded, a clinical diagnosis of NAFLD can be made. The second stage involves risk stratification to determine a patient's stage of disease. This should be initially undertaken non-invasively with a locally available test (eg, FIB-4 score, NAFLD fibrosis score, TE, ARFI, CK-18). Patients who are identified as 'low' risk of NASH or advanced fibrosis can be managed in primary care with modification of their metabolic risk factors. Patients who are 'indeterminate' or 'high' risk should undergo further assessment (often requiring a liver biopsy) to determine the stage of disease. Risk stratification means patients can then be managed appropriately as will be discussed in 'Non-alcoholic fatty liver disease: a practical approach to management' by Dyson et al65a.
Machado et al have recently proposed a similar algorithm for patients with NAFLD to guide when liver biopsy is needed. They used the NAFLD Fibrosis Score and TE to evaluate fibrosis and CK-18 fragments to evaluate NASH. The management pathway for patients would be very similar as with the algorithm we propose, but CK-18, and even TE, are not available in many centres, which is reflected in our algorithm.
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